Bariatric (Weight Loss) Surgery

POST OP PROTOCOL; Gastric Bypass

Day 0: Day of surgery

• May have sips of water up to 30mls per hour
• Encourage mobilisation
• IV Omeprazole as charted
• STOP all diabetic medication
• Regular anti-emetic as charted
• Strict fluid balance - show patient how to record this themselves
• Sub-cut Clexane as charted
• TEDS should still be in place from admission

Day 1: Post op

• Start sips of water 30ml/hr. If well tolerated increase to 60ml/hr. by mid-day
• Stop IV fluids once tolerating 60ml per hour
• Strict fluid balance - patient to record fluids themselves
• Can change to oral medication - these must be crushed or capsule opened

IV Omeprazole change to oral Pantoprazole 20mg daily

Contents swallowed only, capsule to be discarded

• Remind patient to re-read the dietitian information Day 2 post op (if not discharged day 1)
• Increase oral fluids to 100mls per hour if tolerated and introduce dilute Optifast as above
• Can begin Berocca performance (dilute) once daily or wait until discharge - Optifast is more important at this stage
• Aim for discharge

Discharge plan

• Paracetamol (dissolvable or suspension) Q4-6H for at least 48hrs
• Pantoprazole 20mg PO daily for the next 12 months due to risk of developing a gastric ulcer. Crush until 3-4 weeks post procedure
• Centrium Advance 50+ (x2 per day) once on pureed diet (2-3 weeks post procedure) or Celebrate Bariatric Multivitamin (chewable, one per day) on discharge
• Crush all usual medications (or open capsules) for at least 1-2 weeks
• Dietitian sheets and vitamin supplement sheets given to patient with contact details if any problems arise
• Bowel management (preventative promoted) e.g. alpine tea or Phloe tablets
• Strictly no NSAIDs after Gastric Bypass
• Clinic review approx. 2 week post op

Week 1: Liquids

For the first day after surgery, you'll only be allowed to drink clear liquids.

Once you're handling clear liquids, you can start having other liquids, such as

• Optifast (or similar)
• Broth
• Unsweetened juice
• Decaffeinated tea or coffee
• Milk (skim)
• Sugar-free gelatin or popsicles

Aim for 1.5 - 2.0 litres per day. All drinks should be low in sugar.

Day 5: Pureed foods

After 5 days of tolerating liquids, you can begin to eat strained and pureed (mashed up) foods. The foods should have the consistency of a smooth paste, pudding or a thick liquid, without any solid pieces of food in the mixture. V-8 juice and first-stage baby foods, which do not contain solids, are also convenient options.

As you start to include purees into your diet, it's important not to drink fluids while you eat.

You can eat three to six small meals a day. Each meal should consist of 4 to 6 tablespoons of food.

• Eat slowly - about 30 minutes for each meal Choose foods that will puree well, such as:
• Lean ground meat, poultry or fish, cottage cheese, soft scrambled eggs , yogurt, white fish, cottage cheese, ricotta, cooked cereal, soft fruits and cooked vegetables (applesauce, bananas, canned fruits, peaches, apricots, pears, pineapples, melons), strained cream soups Blend solid foods with a liquid, such as:
• Water, Skim milk, Juice with no sugar added, Broth Practical tips to help meet Nutritional Requirements at Pureed Stage:
• Each meal should include a high protein food item
• Protein shakes should be included to help ensure an adequate protein intake and protein powder can be added to meals to increase the protein content

Spicy seasonings may irritate the stomach, so avoid these completely or try them one at a time.

Avoid fruits that have lots of seeds, such as strawberries or kiwifruit. You should also stay away from foods that are too fibrous to liquefy, such as broccoli and cauliflower.

Weeks 3-5: Soft foods

After a few weeks of pureed foods you can start soft diet (generally week 4). They should be small, tender and easily chewed pieces of food.

You can eat three to five small meals a day. Each meal should consist of one-third to one-half cup of food. Chew each bite until the food is pureed consistency before swallowing.

Soft foods include:

• Ground lean meat or poultry, Flaked fish, eggs, Cottage cheese, cooked or dried cereal, rice, canned or soft fresh fruit, without seeds or skin, cooked vegetables, without skin

Include 1 protein shake per day as part of fluid intake

• Optifast® shakes / soups / desserts (Pharmacies, pharmacydirect.co.nz)
• Red8 Protein Plus, Whey or Soy Protein (Health 2000 stores, pharmacydirect.co.nz)
• Balance, 100% Whey Protein (Health 2000 stores, pharmacydirect.co.nz)
• Clean Lean Protein Pea (Health 2000 stores, Hardys, pharmacydirect.co.nz)

>6 Weeks: Solid foods

After about 6 weeks on the gastric bypass diet, you can gradually return to eating firmer foods. Start with eating three meals a day, with each meal consisting of 1 to 1- 1/2 cups of food. It's important to stop eating before you feel completely full.

Depending on how you tolerate solid food, you may be able to vary the number of meals and amount of food at each meal. Talk to your dietitian about what's best for you.

Try new foods one at a time. Certain foods may cause pain, nausea or vomiting after gastric bypass surgery.

Foods that can cause problems at this stage include:

• Breads, carbonated drinks, raw vegetables, cooked fibrous vegetables, such as celery, broccoli, corn or cabbage, tough meats or meats with gristle, red meat, fried foods, highly seasoned or spicy foods, nuts and seeds and popcorn

Post Operative Follow-up

Surgical review

• Week 2
• 3 months
• 9months following surgery

Stop Omeprazole at 6 weeks

Dietician post op

• Week 3
• 3 months
• 8 months
• 12 months
• 18 months
• 2 years

Psychologist / Group Sessions

• As required / desired

Long Term Considerations

• Eat Slowly
  • Chew your food 20 times before swallowing
• Ensure you eat enough protein
  • Eat your protein before your carbohydrates
• Avoid liquids with meals (do not drink within 30 mins before or after meals)
• Exercise at least 30mins 4-5 times per week
• Avoid alcohol, 6 months
  • Your tolerance to alcohol may be significantly lower postoperatively
• Try to limit caffeine in taking to 1-2 cups per day
• Avoid pregnancy for 12 months post surgery
  • Use contraception during this waiting period (oral contraception may be less effective)
  • Get regular blood tests to look for nutritional deficiencies. You may need additional supplements
  • See a Dietician to help regulate weight gain during pregnancy
• Always carry drink bottle on your person
  • To sip clear fluids over the course of the day
• Try to carry / have handy a protein bar (or similar) to eat if feeling fatigued / low blood sugar
• We strongly recommend that you NEVER smoke postoperatively
  • Smoking is the main contributor to Gastric pouch ulceration
• Avoid Non-Steroidal Anti Inflammatory pain relief (NSAID's)
  • Increase Gastric pouch ulceration
• Continue Multivitamin / Calcium / Vitamin D tablets lifelong
• Monitor vitamin B12 with 6 monthly blood tests
  • You may require a vitamin B12 injection if low
• Dumping syndrome can occur after eating a high sugar meal / sweets
  • Can make you feel unwell (Dizziness / pain / flushes / cramps / diarrhoea).
  • This is self limiting / Not harmful
  • Immediately after eating, or delayed by 2-3 hours
  • Managed by avoiding sweet / high sugar foods and increasing fluid intake
• Constipation can be an issue. Laxatives may be required as oral fibre intake may be low.
  • Best to avoid Lactulose